Mending the Net

Several years ago, a young woman visited health clinics in Fort Wayne, Ind., with symptoms that included a cough and low fever. Each doctor noted her symptoms at the time, but none of them learned about her exams at the other clinics, said Meg Distler, executive director of the St. Joseph Community Health Foundation.

Without a complete picture of the woman's medical condition, the doctors failed to see she had tuberculosis. The disease eventually killed her.

"If they had seen a whole chart, it would have been obvious," Distler said.

Local health-care organizations were already discussing how "safety net" clinics -- those that serve patients with no health insurance and patients on Medicaid -- could share information to gain complete medical histories for their patients. The woman's story served as an emotional trigger, spurring organizations in Fort Wayne to take action.

The result was the Health Access Program (HAP), an application that places patients' information in a central repository for easy sharing. Building complete medical histories for patients at safety net clinics is often a challenge.

"A lot of the patients we see at our clinics tend to bounce around to a lot of the other clinics," said Dave Fiess, informatics director of the Fort Wayne-Allen County Health Department, which operates four safety net medical facilities.

Local health officials didn't realize how dire the problem was until they implemented electronic medical records (EMR) systems. Then they discovered that 20,000 patients were seen in more than three locations, said Doug Horner, co-founder and president at Medical Informatics Engineering (MIE), the Fort Wayne company that developed HAP.

A patient doesn't always remember to relate all the details of his or her medical background, such as past illnesses and treatments, medications, surgeries and parents' medical histories. If much of that information is inaccessible because it's filed at other clinics, the attending physician could lack potentially critical information.

The St. Joseph Community Health Foundation, a private, faith-based organization, laid the groundwork for HAP by providing grants to local clinics to implement EMR systems. All of them chose MIE's program, Web Chart, which most private physicians' offices in the area use as well, Distler said. Then the foundation and the clinics started to look at ways to connect their separate Web Chart databases.

"I can't say there was one 'aha!' moment when the idea of connecting them came up," Distler said, adding that the story of the woman with tuberculosis pushed the process along.

The foundation provided the computer hardware and funding for someone to coordinate meetings where participants could hammer out the details of the new system, and MIE contributed the software development.

Privacy, Accountability
Officials from local hospitals lent their expertise to make sure the system complied with the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA).

"The local hospitals were very generous in helping to walk through each of the steps with their compliance officers, to make sure that what we did was really at the top letter of the law," Distler said.

The governing bodies of all four clinics had to agree on procedures they would use to get permission from patients to share their information, she said, and the clinics share information only on patients who give written consent. Participants also had to agree on accountability procedures, to make sure records shared through HAP aren't misused.

Clinics that have implemented Web Chart and HAP include: Matthew 25 Health and Dental Clinic, a free, faith-based medical facility; the Fort Wayne Medical Education Program family practice clinic, a residency program of the Indiana University School of Medicine; Neighborhood Health Clinics Inc., a private nonprofit organization; and Fort Wayne's four city-county Health Department clinics, which specialize in sexually transmitted diseases, tuberculosis, lead poisoning and refugee care.

The Health Department was the last to start using HAP because it implemented Web Chart later than the others, in early 2005, Fiess said.

Most medical offices use a hosted version of Web Chart, which runs in an MIE data center. HAP is just another Web Chart system, Horner said. Its database provides a repository for data from all participating clinics.

At the Health Department clinics, when a new patient calls for an appointment, the receptionist creates an electronic record in Web Chart, entering information such as the patient's name, sex, birth date and Social Security number.

When the patient arrives for the appointment, HAP checks that information against its database to find out whether any other participating clinics have seen that patient. If it finds a match, it alerts the operator. The software includes an algorithm that compares records, and in the event of a near-match -- for instance, the same sex, birth date and Social Security number but a different last name -- the system will present the two records for the operator to evaluate.

If there's a match, Fiess said, the HAP tab will appear for the patient on screen. "The receptionist will then inform the nurse or doctor that this patient has some information in the HAP system."

What You Scan Is What You Get
Although they're using an EMR, the clinics also continue to record information on paper. The software lets them print out the forms they use in their exams; later, employees scan the completed paperwork into the system, Fiess said. When an employee in one clinic uses HAP to access another clinic's records, he or she sees the scanned documents.

"If clinic A handwrites it, that's what you see. If it types it, that's what you see," Distler said, adding that this flexible design decision was significant. "It's working very well, because everyone's using it as part of their process, versus trying to force people to take on a new process that they may or may not have liked."

A second phase of the HAP rollout will bring local hospitals into the system. That will start with a pilot in an emergency room, Distler said. At first, hospital personnel will be able to pull up records for Medicaid patients, or patients without insurance, who have been seen at one or more safety net clinics. In the next step of the development, Distler added, hospitals will determine which of the collected data they will send to HAP. "They don't want to kick back everything, for a lot of confidentiality reasons."

Once the emergency rooms of Fort Wayne's two hospital systems are up and running on HAP, the hospitals' obstetrics departments probably will start using it as well, Distler said.

The Fort Wayne-Allen County Health Department hasn't been using HAP long enough to get a good handle on how effective it's been, said John Silcox, communications director for the department. "We're probably going to have a little more of an idea and a way to quantify its success once we've been using it longer."

Clearly many benefits arise from giving physicians more complete information about the patients they see. For example, if a patient visits a city-county health clinic and later goes to another facility, the physicians there can see the medicines prescribed, so they don't prescribe something that can't go with it, Fiess said.

HAP aside, simply moving to electronic medical records has greatly improved service to patients, said Distler. For example, at Matthew 25's free clinic, where volunteers process and maintain medical charts, a patient visit used to take as long as five hours. Now, using the EMR, the clinic whittled that time down to probably two hours to go in, get an exam and go through the dispensary, she said.

Along with providing benefits to patients and clinics, Fort Wayne's HAP project offers an excellent example of a public-private partnership, Distler said.

"To get that kind of collaboration in a community over five years is a wonderful thing. It's a real testament to a lot of people who really are working on good solutions for health care."